MEDICARE: MS. KATHLEEN DAWELLA MOSLEY SPECIMEN COLLECTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246RP1900X	Phlebotomy Technician	R7H4P2Q8	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1356899405	OTHER	OH	NPI

General Provider Information

NPI Number	:	1356899405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN DAWELLA MOSLEY SPECIMEN COLLECTOR

Provider Business Mailing Address
First Line	:	4479 BROADVIEW RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-4302
Country	:	US
Telephone Number	:	216-916-9282
Fax Number	:	216-823-0518

Provider Business Practice Location Address
First Line	:	4479 BROADVIEW RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-4302
Country	:	US
Telephone Number	:	216-916-9282
Fax Number	:	216-823-0518

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	09/19/2016

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